Provider Demographics
NPI:1629337167
Name:YACOBOV, BAHUR (OPTICIAN)
Entity Type:Individual
Prefix:
First Name:BAHUR
Middle Name:
Last Name:YACOBOV
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8113 LEFFERTS BLVD
Mailing Address - Street 2:
Mailing Address - City:KEW GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11415-1727
Mailing Address - Country:US
Mailing Address - Phone:718-849-0847
Mailing Address - Fax:718-849-0864
Practice Address - Street 1:8113 LEFFERTS BLVD
Practice Address - Street 2:
Practice Address - City:KEW GARDENS
Practice Address - State:NY
Practice Address - Zip Code:11415-1727
Practice Address - Country:US
Practice Address - Phone:718-849-0847
Practice Address - Fax:718-849-0864
Is Sole Proprietor?:No
Enumeration Date:2012-05-03
Last Update Date:2012-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6538156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician